Trauma nursing is a complex and ever-changing, evidence-based field. It is well known that best patient outcomes are achieved when all providers involved are experts within their specialty. Working as an effective trauma nurse requires extensive experience in emergency and critical care concepts of nursing. Leaders in trauma nursing care should be recognized, utilized, and encouraged to grow within their field. This is exactly what one hospital in South Carolina is doing in order to provide optimal trauma patient care.
Grand Strand Medical Center (GSMC) is a 325-bed, Level I adult, Level II pediatric trauma center located in Myrtle Beach, SC. The hospital serves as the only Level I trauma center in Horry and Georgetown counties, providing care to several other surrounding counties in both North and South Carolina. In addition to serving area residents, GSMC cares for vacationers from around the world, particularly in the spring and summer months. GSMC was first verified as an American College of Surgeons Level II trauma center in 2012, obtaining Level I adult and Level II pediatric designation in May 2017. GSMC's specialty units include surgical intensive care, cardiovascular intensive care, and interventional radiology. Furthermore, it is home to the area's only neurosurgery and pediatric intensive care unit (PICU) specialties. Ensuring efficient and effective delivery of care within the trauma services department is a robust team of attending surgeons; resident physicians; advanced practitioners; registered nurses; an emergency medical services (EMS) coordinator; registrars; and research, performance improvement and patient safety (PIPS), and injury prevention specialists.
Within GSMC's trauma services department are 11 registered nurses with the title of Trauma Nurse Lead (TNL). These nurses have an extensive background in emergency, trauma, and critical care nursing, with some carrying Trauma Certified Registered Nurse (TCRN), Certified Emergency Nurse (CEN), and/or paramedic licensure. In addition, several are currently expanding their knowledge and leadership skills through graduate school and nurse practitioner programs. TNLs are experts in clinical care and in disseminating education to trauma care providers in the form of Trauma Nursing Core Course (TNCC), Advanced Trauma Care Nursing (ATCN), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Emergency Nursing Pediatric Course (ENPC) classes. They are also proficient in the facility's anticoagulation reversal protocols (ACRPs) and massive transfusion protocols (MTPs).
There are always two dedicated TNLs staffed within the hospital, 24 hours a day, 7 days a week. The TNL's primary role is to provide expert nursing care to trauma patients when they arrive in the emergency department (ED). They assist with primary and secondary surveys, obtain vital signs, attain and assess intravenous or intraosseous access, administer medications and blood products, assist with wound care and splinting, and coordinate with radiology, the operating room (OR), the nursing supervisor, and the intensive care units (ICUs). TNLs also ensure that a physician complete a predeparture checklist before each patient leaves the trauma bay for his or her computed tomographic (CT) scans. TNLs then follow patients through to CT scan and any critical interventions, ensuring safe transition and delivery of care to final disposition, while remaining available to assist with continuing care if needed.
TNLs report directly to the trauma program leadership. Without patient care room assignments outside the trauma resuscitation bays, TNLs are available to follow critically ill patients throughout the hospital, from resuscitation until stabilization. They attend daily sign-out rounds with the attending and resident physicians and round daily in the ICUs and all other floors receiving trauma patients. In addition, they attend twice-weekly multidisciplinary rounds to facilitate care of trauma patients with attending and resident physicians, case managers, physical therapists, dieticians, and various department nurse leaders, as well as monthly trauma quality meetings. Furthermore, TNLs are available to assist with MTPs and ACRPs throughout the hospital, act as a clinical support resource, and assist with education and procedures in the ED, ICUs, and on the floors. They also play a crucial role in reuniting patients with family members and loved ones.
Being on the front line of trauma patient care, TNLs play a vital role in the PIPS program. TNLs are knowledgeable of trauma audit filters and performance improvement (PI) initiatives, allowing for real-time event identification, resolution, and further reporting to trauma program leadership. TNLs complete patient case summaries and have designated PI projects for which they are responsible. Examples of these projects include but are not limited to MTPs, ACRPs, blunt cardiac injury, capnography utilization, documentation compliance, and acute kidney injury. Data-driven process changes occur as a result of these efforts.
Furthermore, TNLs are extensively involved with research and outreach. They are actively involved in all steps of the research process, contributing to the greater body of knowledge related to trauma. TNLs have an active role in community outreach programs such as EMS case reviews, newsletters, health fairs, fall prevention initiatives, and the Stop the Bleed campaign.
Extensive literature review demonstrates very few published works regarding the role of specialized nurses in trauma resuscitation. Seislove (2006) reported that “the core trauma nursing staff has been pivotal in establishing coordination, facilitation, communication, and clinical efficiencies to trauma resuscitations...” (p. 138). Furthermore, the author demonstrated that triage time to diagnostics decreased, positive perceptions of care by patients and family increased; and staff nurse, physician, and ancillary staff satisfaction improved.
Wurster, Coffey, Haley, and Covert (2009) set out to provide the most experienced nurses at the bedside in order to identify any problems with trauma resuscitation. They found that with the creation of a Trauma Nurse Leader role, communication and documentation improved. They also stated that “...the TNL group is highly respected in the hospital. With this respect comes the desire to perform at a higher level than might generally be expected” (p. 161).
One Level III adult trauma center established a Trauma Nurse Leader program to allow for focused education and protocol compliance through repetition of trauma participation (Geyer et al., 2016). After implementation, documentation had improved and a 10-min reduction in ED length of stay was demonstrated.
The TNL role at GSMC was established in September 2015 after the need for specialized trauma nursing care was recognized. Prior to the addition of this role, ED registered nurses, who were assigned other ED rooms, would care for arriving trauma patients. This created a varying degree of expertise with limited exposure to trauma volumes that restricted demonstration of competence and generated burnout and compassion fatigue. PIPS initiatives identified opportunities in care. There were varying levels of competence for the most critical patients as well as a lack of consistency in following evidence-based protocols such as MTP and ACRP.
A single-center retrospective study of all trauma activations over a 3-year period was conducted (January 2014–December 2016; n = 9,625). Data were divided into two comparison groups, pre-TNL (January 2014–August 2015) and post-TNL (September 2015–December 2016). Patient outcomes were reviewed in this comparison analysis to evaluate the efficiency of the TNL program. It was hypothesized that post-TNL implementation data would show quality improvements in performance measures and patient outcomes, with observed improvements in staff satisfaction. Institutional review board approval was obtained prior to this retrospective study. All contributing authors of this study have undergone training and proven competency with the Collaborative Institutional Training Initiative Protection of Human Research Subjects course.
Descriptive statistics, including mean, standard deviation (SD), frequency, and percentage were used to determine data characteristics of pre-TNL implementation data compared with post-TNL implementation data. Patient demographics, injury severity, and outcomes were reviewed. The primary outcome between the two comparison groups in consideration was mortality. Secondary outcomes included arrival time to start of MTP, arrival time to ACRP activation time, arrival to administration of tranexamic acid (TXA), ED disposition status, disposition times, hospital length of stay (LOS), and ICU LOS. Continuous variables were compared using a two-sample t test or Wilcoxon–Mann–Whitney U test, whereas categorical variables were compared using a χ2 or Fisher's exact test, as appropriate. All p values of less than .05 were considered significant. Statistical analyses were performed using QI Macros for Excel (2012; KnowWare International, Inc., Denver, CO).
Table 1 demonstrates the comparative demographics between pre-TNL program implementation patients (n =5,328) and post-TNL program implementation patients (n = 4,297). The distribution of the Injury Severity Score (ISS) among the two study populations differed, with pre-TNL study group ranking higher (p < .001; pre-TNL sum of ranks: 24,309,854.50; pre-TNL median: 7.6; post-TNL sum of ranks: 19,359,330.50; post-TNL median: 7.2; z-score: 3.283223233). Trauma patients treated after implementation of the TNL program were 1.5 times more likely to present with injuries requiring ICU admission (p < .001; odds ratio = 1.53 [1.4–1.7]). The mortality rate of the two comparison groups remained equivalent (p = .934) while secondary outcomes improved, as summarized in Table 2. Mean hospital LOS decreased by one full day, from 5.6 to 4.6 days (p < .001). Mean ICU LOS also decreased, from 6.2 to 4.8 days (p < .001). Furthermore, the average LOS among patients receiving MTP decreased from 35.1 to 21.6 days (p = .012), as shown in Table 3. The arrival to administration of TXA time dropped, from 54.6 to 31.6 min on average (p = .018). Arrival to start of MTP times decreased from 36.5 to 29.2 min post-TNL program commencement, showing vast improvement despite a lack of statistical significance (p = .331). Prior to the start of the TNL program, in the second quarter of 2015, ACRP activation time was 163 min on average. During Quarter 2 of 2017, it was 61 min (p = .035). In addition, overall arrival to ICU disposition times decreased by 20%, from 150 to 120 min, and overall arrival to OR disposition times decreased by 15%, from 120 to 102 min.
The TNL program has made a prodigious impact on patient care at GSMC. Quantifiers such as LOS, ICU LOS, and arrival time to ACRP activation are demonstrations of PI following program implementation. Furthermore, the program has ensured the presence of highly trained trauma nurses at all times. These nurses are intimately familiar with all aspects of trauma care throughout the hospital and the units that are served. TNLs provide trauma team coordination and patient continuity of care from arrival to discharge, optimizing patient outcomes and support of the trauma team. Physician satisfaction has increased, knowing that timely and efficient care will be provided, with adherence to trauma center protocols. In addition, TNLs are able to recognize physiological deterioration and anticipate physician interventions and orders.
In addition to receiving positive physician feedback, TNLs have had many opportunities to witness their impact on the trauma patient firsthand. Several former trauma patients, some who were at one time quite critical, have returned to the hospital for what is known as a victory lap. During this visit, former patients can share their stories of healing and recovery with staff. This leaves an inspiring impact on all involved, including TNLs, as they may otherwise be unaware of these positive long-term outcomes after discharge.
No change worth making is without growing pains. Challenges arose and were met during implementation of the TNL program. It resulted in a change of culture for the nurses working in the TNL role, as well as for staff in the ED and ICUs. TNLs adjusted to not having an assignment in the ED. Not always needing to be present in the ED, TNLs were now available to assist elsewhere in the hospital and to take on an active role in PIPS. After going through a transitional period of uncertainty regarding their role in the trauma bays, ED nurses now recognize TNLs as an excellent resource, especially during multiple trauma activations. Critical care nurses in ICUs have come to appreciate the TNL trauma expertise and call on them with questions or concerns. Education remains ongoing for ED and ICU nurses, including TNCC and a trauma operations course being periodically offered to help ease this transitional process and clarify responsibilities.
A culture change was required from the perspective of hospital administration as well. Dedicated full-time equivalents were required, and staffing metrics were adjusted in the creation of the TNL role. Administration has embraced the program, seeing the value it provides to the entire hospital.
Furthermore, although the program is exceeding expectations, there are goals moving forward for further development at both the team and facility levels. One example of this is increasing PICU nurse involvement in pediatric initial resuscitation and ongoing collaborative education. The program has the potential to assist other trauma centers with initial rollout of their own dedicated trauma nurse program. A long-term goal for this program is to host an external trauma nurse fellowship to bridge the gap of trauma education across the country. Although Advanced Trauma Life Support is taught within GSMC, bringing ATCN on board and building the instructor base for further staff development are now considered crucial.
On the basis of this single center's findings, it is recommended that trauma centers consider the implementation of a TNL program. The use of TNLs will enhance PI measures and optimize patient outcomes. With the consistent availability of highly trained and specialized trauma nurses, trauma patients are cared for more efficiently and in a timely manner. ED nurses are complemented with trauma expert nursing assistance, providing an environment with additional time to focus on their already busy daily agendas. Following the implementation of a TNL program, overall physician and staff satisfaction will improve and the risk of ED nursing burnout will decrease.
Moving forward, the TNL program at GSMC will continue to evolve and expand. It will remain a source of education to all hospital staff members involved in the care of trauma patients. TNLs will also continue to advocate for the trauma needs of the community. Furthermore, they will constantly expand their trauma expertise, as they continue to live out their passion for trauma nursing.
- TNLs are able to provide expert clinical care throughout the trauma continuum, enhancing PI measures and optimizing patient outcomes.
- Expert clinical nursing care leads to decreased time to lifesaving measures and to decreased hospital LOS.
- Use of TNLs ensures effective assistance in the trauma bay while alleviating ED nurses from the added responsibility, increasing both physician and staff satisfaction while reducing burnout.
This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity.